Clostridium difficile Infection (CDI) Gail Bennett, RN, MSN, CIC - - PowerPoint PPT Presentation
Clostridium difficile Infection (CDI) Gail Bennett, RN, MSN, CIC 1 Clostridium difficile (C.difficile) Antibiotic induced diarrhea Can cause pseudomembranous colitis Most common cause of acute infectious diarrhea in nursing homes
1
Gail Bennett, RN, MSN, CIC
2
Antibiotic induced diarrhea Can cause pseudomembranous colitis Most common cause of acute infectious
diarrhea in nursing homes
Disease may be a nuisance or cause life
threatening colitis
Increasing numbers of cases
Cases have tripled in US hospitals from 2000 until
2005
Increasing disease severity and mortality
3
May cause approximately 30% of cases of
healthcare associated diarrhea
Colonization rate of C. difficile
About 10-25% of hospitalized patients Long term care residents 4-20%
Antibiotic therapy may disrupt normal colonic
flora in colonized patients and C. difficile proliferates, producing toxins and symptomatic disease
4
Antimicrobial exposure Length of stay in a healthcare facility Advancing age Serious underlying illness History of non-surgical GI procedures Presence of a nasogastric tube Suppressed immune system
5
Clindamycin Ampicillin Amoxicillin Cephalosporins Fluoroquinolones
6
A new strain is circulating in the U.S. ,
Produces large quantities of Toxins A
More severe disease, higher mortality
7
Toxin testing
Quick – same day
Stool culture
Takes 48-96 hours
Testing for C. difficile should be done
8
Discontinue antibiotics if possible Fluid and electrolyte replacement Do not use antimotility agents
9
Metronidazole (Flagyl) 250 mg QID or
Vancomycin 125 mg QID - used if
Experimental fecal transplant (enemas)
10
Rates of recurrence
20% after 1st episode 45% after 1st recurrence 65% after two or more recurrences
No reports of Metronidazole or
11
effectively and safely care for patients undergoing particular treatments with inherent risks
interventions
improve clinical outcomes
best care (“All or nothing”)
12
C. difficile transmission prevention activities during
routine infection prevention and control responses (basic)
C. difficile transmission prevention activities during
heightened infection prevention and control responses (enhanced)
Evidence of ongoing transmission of C. difficile, an
increase in CDI rates, and/or evidence of change in the pathogenesis of CDI (increased morbidity/mortality among CDI patients) despite routine preventive measures
13
Hand hygiene Contact precautions Identification of cases Environmental disinfection Appropriate use of antibiotics
14 For basic measures,
may use alcohol handrubs with C. difficile – OR use soap and water
Perform hand hygiene
before contact with
the patient
after removing gloves after contact with the
environment
15 For enhanced
measures, do not use alcohol handrubs with the CDI patient – use soap and water
Washing away the
spores may be the
perform hand hygiene when transmission of
16
17
Hand hygiene Contact precautions Identification of cases Environmental disinfection Appropriate use of antibiotics
18
Designed to reduce the risk of transmission of
microorganisms by direct or indirect contact
Direct contact
skin-to-skin contact physical transfer (turning patients, bathing
patients, other patient care activities)
Indirect contact
Contaminated objects
19
Resident placement
Private room preferred 2nd option: Cohorting with other resident with C. difficile 3rd option: In LTCFs, consider infectiousness and resident-
specific risk factors to determine rooming with a low risk roommate and socializing outside the room
Consider:
Clean Contained Cooperative Cognitive Patient care equipment (dedicated to single resident if
possible) if not, disinfect equipment prior to leaving the room
20
Contact Precautions - gloves and gowns
Do not re-use gowns Supplies outside the room Keep cubicle curtain drawn to limit
21
May discontinue precautions when
Do not do a toxin “for cure” once
Lab should not accept stool for toxin if
22
How is C. difficile-associated disease
usually treated?
After treatment, repeat C. difficile testing is not recommended if the patient’s symptoms have resolved, as patients may remain colonized.
http://www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html
23
Environmental contamination
24
~ Contaminated surfaces increase cross-transmission ~
Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.
25
26
Consider increasing frequency for C. difficile
and VRE
For C. difficile, may use a hypochlorite based
germicidal agent
Less labor intensive to use an EPA registered,
hospital grade pre-mixed hypochlorite product rather than trying to mix a bleach solution daily
Consider cleaning those rooms at the end of
the cleaning shift or change water and mop heads after each C. difficile room.
Several disinfectants now have EPA
registration against C diff spores
27
28
Hand hygiene Contact precautions Identification of cases Environmental disinfection Appropriate use of antibiotics
29
Colonization or asymptomatic fecal carriage of
May be common in healthcare facilities Studies have demonstrated colonization in LTCF
residents in the absence of an outbreak has ranged from 4% to 20%
C. difficile associated disease
Acute diarrhea
30
Basic Strategy:
With cases of diarrhea, consider C. difficile
Take a detailed history for risk factors
Norovirus, dietary changes, medications, and
Notify physician Watch for dehydration
31
Enhanced Strategy:
Automatic contact precautions for all patients
with orders for C. difficile labs
Allow nurses to initiate the lab order and
contact precautions
32
Contact precautions Hand hygiene Identification of cases Environmental disinfection Appropriate use of antibiotics
33
Contact precautions Hand hygiene Identification of cases Environmental disinfection Appropriate use of antibiotics
34
Hospitals generally have good
35
36
37
42 CFR §483.25(l), F329, Unnecessary Drugs Determine if the facility has reviewed with
the prescriber the rationale for placing the resident on an antibiotic to which the
resident remains on antibiotic therapy without adequate monitoring or appropriate indications, or for an excessive duration
38
What most likely exists currently in your program:
Comparison of prescribed antibiotics with available susceptibility
reports (charge nurse and infection preventionist)
Review of antibiotics prescribed to specific residents during
regular medication review by consulting pharmacist
What may be needed:
Antibiotic stewardship program in the facility (CDC
recommendation – 2006 MDRO guideline)
Broader overview of antibiotic use in your facility with reporting
to quality assurance/infection control committee
Right drug - Right dosage - Right monitoring - Feedback of data to MDs
39
40
41
42
Antibiotic overuse contributes to the growing
problems of Clostridium difficile infection and antibiotic resistance in healthcare facilities.
Improving antibiotic use through stewardship
interventions and programs improves patient
saves money.
Interventions to improve antibiotic use can be
implemented in any healthcare setting—from the smallest to the largest.
Improving antibiotic use is a medication-safety and
patient-safety issue.
http://www.cdc.gov/getsmart/healthcare/inpatient-stewardship.html
43
We must observe to see that our
Educate staff when you see non-
Enforce that all staff must follow the
44
Should not use rectal
Associated with transmission of
enteric pathogens
45
Core Measures High levels of scientific evidence
Contact Precautions for the duration of illness
Hand hygiene in compliance with CDC/WHO
Cleaning and disinfection of equipment and environment
Laboratory-based alert system
CDI surveillance
Education Supplemental Measures Some scientific evidence
Prolonged duration of Contact Precautions
Presumptive isolation
Evaluate and optimize testing
Soap and water for hand hygiene upon exiting the CDI room
Universal glove use on units with high CDI rates
Bleach for environmental disinfection
Antimicrobial stewardship program
46
Clinical Practice Guidelines for Clostridium
difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)
http://azdhs.gov/phs/oids/epi/disease/cdif/documents/Clinical% 20Practice%20Guidelines%20for%20C%20Diff%20Infection%2 0%202010%20update%20by%20SHEA-IDSA.pdf
47
APIC Guide to the Elimination of Clostridium
difficile Infections in Healthcare Settings. http://www.apic.org/Content/NavigationMenu /PracticeGuidance/APICEliminationGuides/C.di ff_Elimination_guide_logo.pdf
SHEA: Clostridium difficile in Long Term Care
Facilities for the Elderly http://www.shea-
Cdiff.pdf
48
Spotlight on Clostridium difficile
David P. Nicolau , PharmD, FCCP,
49
Clostridium difficile (CDI) Infections
Toolkit (pdf)
CDI Toolkit
available in PowerPoint format
Clostridium Difficile Infection (CDI) Baseline
Prevention Practices Assessment Tool For States Establishing HAI Prevention Collaboratives Using ARRA Funds Using Recovery Act Funds
http://www.cdc.gov/HAI/recoveryact/stateResources/toolkits.html
50
Protect patients…protect healthcare personnel… promote quality healthcare!
gailbennett@icpassociates.com www.icpassociates.com